Simulated Patient Scenario

Scenario Details

MDT Information

• Non-urgent response - Welfare Check / Decreased Function
• 78-year-old female, noted decline by family
• Possible depression / self-neglect
• Patient is awake but withdrawn
• Adult child present

On Arrival

Paramedics arrive at the patient's home. The patient's adult daughter meets them, expressing concern about her mother's decline over the past few months, especially since the death of her husband 6 months ago. She reports her mother seems apathetic, has lost weight, neglects personal hygiene, rarely leaves the house, and often complains of vague aches and fatigue but dismisses feeling "sad". The patient is sitting in an armchair, looking blankly at the television, appearing somewhat dishevelled.

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (Patient interview - may be difficult, Daughter collateral essential)

Vital Signs/Assessment

Physical Examination (Focused Geriatric/Mental State Assessment)

• **General Appearance/Behaviour:** Appears frail, poor hygiene, flat affect, psychomotor slowing. Limited interaction, poor eye contact.
• **Speech:** Slow, quiet, reduced content.
• **Mood/Affect:** Subjective mood often denied ("fine", "tired"). Objective affect appears flat, apathetic, possibly dysphoric.
• **Thought Content:** May express hopelessness, helplessness, being a burden. Somatic preoccupations (aches, fatigue). Assess suicidal ideation carefully (passive thoughts common, need to probe for active intent/plans).
• **Perception:** No evidence of psychosis.
• **Cognition:** Assess orientation. May show signs of mild cognitive impairment (difficulty with recall, concentration). Consider brief screen (e.g., Mini-Cog, MoCA if trained/time permits). Differentiate from depressive pseudodementia.
• **Insight/Judgement:** Insight into mood/functional decline often poor. Judgement regarding self-care impaired.
• **Risk Assessment:** Assess risk of self-neglect, functional decline, falls, social isolation, and suicide (elderly white males highest risk, but important in all). Consider passive ideation, hopelessness, access to means (e.g., medications).
• **Physical:** Assess for signs of malnutrition, dehydration, self-neglect. Check mobility, balance, falls risk. Brief systems review to screen for medical causes of symptoms (e.g., thyroid disease, anaemia, infection, malignancy, medication side effects).

Assessment and Treatment

Appropriate Management

• Recognise presentation suggestive of major depression in an elderly patient, possibly complicated by grief and mild cognitive impairment. Note significant functional decline and self-neglect.
• **Build Rapport:** Use patient, empathetic approach. Speak clearly (consider hearing impairment). Allow time for responses. Validate feelings of fatigue/being overwhelmed, even if mood is denied.
• **Safety:** Assess immediate environment for safety and signs of severe neglect.
• **Comprehensive Assessment:** Integrate information from patient and daughter. Perform thorough geriatric assessment including mood (consider Geriatric Depression Scale if feasible), cognition, function (ADLs/IADLs), mobility, nutrition, social support, and risk assessment.
• **Involve Family/Carer:** Daughter is key informant and support. Discuss findings, concerns, and plan with her.
• **Rule out/Consider Organic Causes:** Depression in elderly often co-exists with or is caused by medical illness. Maintain high index of suspicion. Basic vitals, BGL, brief physical screen. Transport allows for medical workup (blood tests, etc.).
• **Medical Treatment:** Address any immediate physical needs (e.g., hydration if dehydrated, wound care if injury found). Primarily supportive care pre-hospital.
• **Decision Regarding Transport:** Transport to ED is strongly indicated due to functional decline, self-neglect, weight loss, possible passive death wishes, and need for comprehensive geriatric/medical/mental health assessment. Explain rationale clearly to patient and daughter.
• **Capacity Assessment:** Assess capacity for decision-making, considering potential cognitive impairment and depression. If lacking capacity and refusing transport despite risks, may need involvement of guardianship processes or mental health legislation (jurisdiction-dependent), but often persuasion/family involvement is sufficient.
• **Transport:** Transport patient (with daughter) to ED with geriatric assessment capabilities. Ensure safe mobilisation.
• **Pre-notify:** Inform receiving hospital about elderly patient with suspected depression, functional decline, self-neglect, key history (bereavement), collateral info from daughter, vital signs, cognitive status (if assessed), and request geriatric and mental health assessment.
• Documentation: Detailed record of geriatric assessment components (mood, cognition, function, risk), collateral history, vital signs, physical findings, rationale for transport.